An abbreviated neurologic evaluation should now be performed, including level of consciousness, pupil size and reactivity, and motor function. The Glasgow Coma Scale (XaMe..2.4.3.-.5) should be used to quantify the patient's level of consciousness: possible scores range from 3 (no response) to 15 (high response on all measures). Despite the common comorbid presence of drug and alcohol abuse in trauma patients, it is only safe to assume that patients presenting with a GCS score of less than 15 and an appropriate mechanism have a head injury until proven otherwise. The GCS can be utilized to determine the severity of injury (minor injury GCS 13 and 14, moderate injury GCS 9 to 12, severe injury-coma GCS 3 to 8) and therefore the urgency with which the CT scan is obtained. New head injury guidelines have been formulated by an evidence-based methodology performed by the Brain Trauma Foundation in conjunction with the American Association of Neurological Surgeons. «11 Among the updated recommendations are (1) a suggested guideline for the placement of devices for intracranial pressure (ICP) monitoring for head-injured patients with GCS scores of 3 to 8 and a traumatic intracranial lesion and (2) concerns about prolonged prophylactic hyperventilation in the absence of an identified increase in ICP. The result of these two recommendations produces a heightened emphasis on the importance of the head CT scan. Only a head CT would identify the intracranial lesion that would lead to placement of an ICP catheter, and it is only with identification of such an increase in ICP that prolonged hyperventilation (until recently a practice routinely taught) can be justified. Accordingly, patients who are comatose after head injury should be intubated with in-line neck immobilization and transported to the CT scanner with the same sense of urgency that a hypotensive patient with a gunshot wound to the abdomen would be rushed to the operating room.
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